Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
JOSEPH CAPRIOLI AND ANNE L. COLEMAN, ON BEHALF OF THE BLOOD FLOW IN GLAUCOMA
DISCUSSION GROUP
● PURPOSE: To provide a critical review of the relation- priate methods to evaluate their blood flow. There are also
ships between blood pressure, ocular blood flow, and cardiovascular safety concerns associated with treatments
glaucoma and the potential for glaucoma treatment designed to increase ocular perfusion pressure and blood
through modulation of ocular perfusion. flow by increasing blood pressure, especially in elderly
● DESIGN: Summaries of the pertinent literature and patients. For these reasons and with present evidence it is
input from glaucoma researchers and specialists with unlikely that safe and effective glaucoma treatments based
relevant experience. on altering optic nerve perfusion will soon be available.
● METHODS: Review and interpretation of selected liter- (Am J Ophthalmol 2010;149:704 –712. © 2010 by
ature and the results of a 1-day group discussion involv- Elsevier Inc. All rights reserved.)
ing glaucoma researchers and specialists with expertise in
epidemiology, blood flow measurements, and cardiovas-
G
LAUCOMA IS A FAMILY OF OPTIC NEUROPATHIES
cular physiology. having in common a characteristic cupping of the
● RESULTS: Accurate, reproducible, and clinically rele-
optic nerve head and a distinctive pattern of visual
vant measurements of blood flow within the optic nerve field loss for which increased intraocular pressure (IOP) is an
head and associated capillary beds are not fully achievable
important risk factor. From the time of its earliest recognition,
with current methodology. Autoregulation of blood flow
there has been a debate about its etiology and preferred
in the retina and optic nerve head occurs over a large
treatment. Elevated IOP has long been thought to increase
range of intraocular pressures and blood pressures. Reg-
the risk of glaucoma by causing abnormalities of the optic
ulation of choroidal blood flow is provided by a mix of
nerve head at the level of the lamina cribrosa, affecting the
neurohumoral and local mechanisms. Vascular factors
may be important in a subgroup of patients with primary intracellular transport within the retinal ganglion cell axons
open-angle glaucoma, and particularly in patients with or by causing vascular abnormalities that lead to ischemic
normal-tension glaucoma and evidence of vasospasm. damage. When von Graefe introduced iridectomy as a suc-
Low ocular perfusion pressure and low blood pressure are cessful treatment for acute glaucoma in the mid-1800s, he
associated with an increased risk of glaucoma in popula- postulated that it was helpful because it reduced aqueous
tion-based studies. The physiologic nocturnal dip in production and IOP, while Jaeger believed that it was helpful
blood pressure is protective against systemic end-organ because it altered ocular blood flow to improve nutrition and
damage, but its effects on glaucoma are not well elabo- decrease inflammation.
rated or understood. Large-scale longitudinal studies The role of IOP as a risk factor for glaucoma is now well
would be required to evaluate the risk of glaucomatous established, and current treatment of glaucoma aims to
progression in non-dippers, dippers, and extreme noctur- reduce IOP to a target pressure low enough to prevent or
nal blood pressure dippers. significantly slow progression.1 The role of optic nerve and
● CONCLUSIONS: Decreases in perfusion pressure and retinal blood flow and ischemia in glaucoma is not clear.2
blood pressure have been associated with glaucoma. How- In the 1990s, Hayreh, Drance, and others raised the
ever, there is no evidence to support the value of increasing important issues of systemic hypotension and nocturnal
a patient’s blood pressure as therapy for glaucoma. Such blood pressure dips in the progression of glaucoma and the
recommendations are not currently warranted, since we desirability of accurate clinical measurements of ocular
lack crucial information about the microvascular beds in blood flow. Interest in these topics has resurged in light of
which perfusion is important in glaucoma, and the appro- recent epidemiologic data concerning low blood pressure
and low calculated “ocular perfusion pressure” as risk
Accepted for publication Jan 8, 2010.
factors for the development and progression of glaucoma.
From the Jules Stein Eye Institute, David Geffen School of Medicine at The purpose of this Perspective is to critically evaluate the
UCLA, Los Angeles, California. current evidence for reduced blood flow in the pathology of
Inquiries to Joseph Caprioli, UCLA David Geffen School of Medicine,
Department of Ophthalmology, 2-118 Jules Stein Eye Institute, Los glaucoma, its measurement, and its iatrogenic perturbation
Angeles, CA 90095; e-mail: Caprioli@ucla.edu as a means of treatment for glaucoma.
THE MEETING OF THE BLOOD FLOW IN GLAUCOMA DISCUSSION GROUP WAS SUPPORTED BY AN UNRESTRICTED GRANT
from Allergan, Inc, Irvine, California. Allergan, Inc had no control over the selection of participants or the selection of discussion topics, which were